Learning to navigate the insurance companies

[JeanettePNP, MSN, RN, NP]

Up to this point I haven't been paying much attention to the reimbursement side of things, but I realize that to support my own professional development I need to become more aware of things like what the reimbursements are for various codes/procedures, what drugs/treatments are or are not covered by particular insurances, etc. How do you get this information? I don't do billing and don't have access to the books. I know what the list price is for each CPT code but I don't know what they actually get from the insurance company.

[lhflanurseNP, APRN]

Various insurance companies have different reimbursement fees. They are all based on a percentage of the medicare fee schedule for your area.

[JeanettePNP, MSN, RN, NP]

How do you find out this information?

[jmillerrn]

Each insurance carrier you are credentialed with can provide a fee schedule so you can look at actual reimbursement rates.

[rnsrgr8t]

As far as medications, each insurance plan/medicaid has a drug formulary that is usually available online. Over the years, I tend to remember which medicaid/insurance covers the majority of the medications I perscribe often. I think Epocrates also has the information on their smartphone APP.

[lostNneuro]

Billing can be very complicated with continuous updates & changes. I recently took a billing seminar for my particular area. It was very helpful. It included many different professionals and numerous MD/NP's in attendance. I think as a provider it is important to have a handle on insurance, but I don't know that I would concentrate on reimbursement rates since they can vary so much. Maybe look into understanding what documentation is needed in order to prior auth particular services in your speciality, or if, heavan forbid, an audit. It would also be helpful to know what has to be billed as a group vs what can billed as seperate charges, etc. It may change the order in which you provide certain services to patients so you can get paid accordingly. And of course, its always helpful to learn those medications/products that are insanely expensive w/ or w/o insurance. Lets face it, if patients can't afford them, it doesn't do any good prescribing them. It's crazy how much power insurance companies have in dictating the type of care patients receive and providers are able to give. Good luck in your journey!